"I am happy that our president got a perfect score of 30 out of 30 on his cognitive screen, the Montreal Cognitive Assessment, or MoCA, a tool commonly used to identify mild cognitive impairment. Passing this test means less than most people think. At all levels of our society, I find that the popular understanding of decision-making “capacity” is not nearly adequate for the silver tsunami of elders in the pipeline. MoCA, and other tests used to judge capacity, only roughly approximate an elder’s fitness to manage his or her life. These tests often fail to catch the nuances that can mean the difference between an elder getting the care they need rather than being swindled out of their life savings.

Almost nothing in my practice drives me more nuts than the relaxed attitude both our society and our medical establishment have toward prescribing sleeping pills and tranquilizers to elders, especially to elders with dementia. As I travel around the San Francisco Bay Area doing house calls and treating people with complicated dementia cases, I often find that my new patients have been treated with sleeping pills or tranquilizers.
Sleeping pills like Ambien or tranquilizers of the “benzodiazepine” class— Lorazepam/Ativan, Alprazolam/Xanax, Triazolam/Halcion, or Clonazepam/Klonopin, to name just a few, there are dozens of brand names—can often cause more troubles than they solve in elders with dementia.
Yes, these drugs do give temporary relief, but the price is often long-term problems.

It’s very common for elders with dementia to have disturbed sleep patterns. Many of my patients would love to sleep all day and stay up all night. But giving a dementia patient a sleeping pill very often makes them much more confused. A much better strategy is to wake the patient during the day when they try to nap. Find activities the elder will enjoy, and then encourage these pleasurable things. Keep an elder’s interest and engagement up will keep them awake during the day and help them to sleep at night. In general, I find that sleeping pills often worsen the symptoms of dementia.

As I’ve described in recent posts, dementia patients often suffer from severe anxiety and delusions. There are times when it’s appropriate to use an anti-anxiety medication for a quick result. Let’s say you’re trying to make it possible for an elder to tolerate a medical procedure, then a tranquilizer might be in order. Or, let’s say an elder has suddenly gotten completely out of control at their residence. If they’re lashing out, screaming and hitting people, a tranquilizer may alleviate the emergency of the moment. But as soon as the chaos is calmed, I always try to get my patients off tranquilizers as soon as possible.

In dementia patients, I have found that prescribing tranquilizers long-term often makes a patient situation worse. Rather than alleviating anxiety or confusion, it often makes those problems more severe in dementia patients. Paradoxically, tranquilizers will make some patients more agitated, not less. I have even had patients who became psychotic on tranquilizers.

Not only this, but tranquilizers are famously addictive. It can be difficult to taper down these medicines once a dementia patient gets used to them. If you discontinue these drugs too quickly, they can cause delirium. Often, I encounter cases where the delirium is blamed on the dementia, but usually the tranquilizers are to blame.

If your elder is on sleeping pills or tranquilizers long-term, those drugs may be the problem, not the solution. Check out our medication section on the ElderConsult website. Then starting asking questions

Earlier this month, a large study cast doubt on whether exercise can help nursing home residents with depression.
The study, published in BMC Medicine, followed more than 1,000 residents in 78 “care homes” in the United Kingdom. It found that the number of elders who participated in exercise classes was low, only about half of the residents attended classes. And it found that only 36 percent attended an exercise class once a week, and that depressed patients attended exercise classes even less frequently than that. It concluded that perhaps nursing home patients are too frail, both physically and mentally, to exercise enough to ease symptoms of depression.

It’s clear that, in this study, exercise alone did not work to help patients suffering from depression.

But I would be very distressed if this study led families and caregivers to conclude that exercise just doesn’t work for depression. The authors of this study acknowledged that the culture of the nursing homes tended to emphasize safety, minimizing the risk of falls, over activity, such as the exercise classes. So perhaps, the problem wasn’t that exercise didn’t help, it was that the culture of the nursing homes didn’t encourage enough exercise to make a difference.

Actually, many recent studies have shown that exercise is one of the few things that can prevent, or delay the onset of dementia. It also seems to help with the symptoms of Parkinson’s disease.

However, the nursing home needs to have a culture that supports exercise, and also supports holistic treatment of depression. That may mean encouraging residents to go to movement classes. It may also mean recognizing that apathy is a symptom of dementia. So that may mean giving appropriate medications that help elders regain the motivation to do things.

Also, don’t ask an elder if he or she “wants” to exercise. Just say, in a cheerful tone of voice, “It’s time for exercise!” And give some ice cream, or another treat, as a reward after exercise class. It’s worked for many of my patients.

Elizabeth Landsverk MD Geriatrician, House calls doctor for Marin, Burlingame, San Francisco, San Jose, Walnut Creek - On call 24/7, working to avoid trips to the ER - Working to reduce medications, and improve enjoyment of every day - See more at: http://elderconsult.com

2) Making sure that the patient’s doctor works with the patient to identify goals and solutions.

3) Arranging for a home visit by the doctor, as one way of paving the way for a home care team.

4) Making “worst-case scenario” plans.

I’m glad that such a prestigious journal published this essay. As a society, we need to talk more about self-neglect. As the essay states, as many as one in ten older adults neglect their own care, and the rate is higher among poor and/or African American elders. We need to talk more about how we balance an elder’s right to make his or her own decisions against his or her safety.

The NEJM essay also makes these points, but then says that “many such people do not have moderate or severe dementia and so are not considered legally incompetent to make health care decisions.”

This is where I differ greatly from the authors. My feeling is that in rare cases, self-neglect may be a choice. Most of the time, as I do geriatric house calls around the San Francisco Bay Area, I find that self-neglect is a huge red flag.

A normally-functioning person simply does not want to live among rotting food, rat feces and piles of junk.

The first question to ask is, “Does this person have the mental capacity to make the choice to live this way?”

Caregivers, family and friends need to push for a full neuropsychological exam in a case like this. The “Mini Mental” exam, asking the person what day it is, or who the president is—that’s not enough to make an accurate judgment of their mental status. Plenty of elders I’ve met know what day it is, but also think they can talk to dead relatives or are happy to give out their bank account numbers to strangers.

If the person does have capacity, then all we can do is to set up a structure (caregiving agencies and so on) that can swoop in if and when the person eventually loses capacity. Families should consult an elder care attorney to know their options. They should try to talk to their elder and ask them what they would want done if they were in the hospital, or if they lost their capacity to make decisions. Sometimes, elders are more open to this kind of conversation when there’s a problem or a crisis.

But most of the time, I find that elder who’s severely neglecting his or her own care does have some kind of dementia or a medical problem.

The authors of the NEJM essay emphasize compromises and working with the patient. Of course, I’m all for that. But remember, it’s next to impossible to negotiate with someone who has dementia. If a person gets a proper psychiatric evaluation—and that’s a full neuropsychological exam—and then is found incompetent to make health decisions, then that person needs to be protected.

That doesn’t mean snatching a person from his or her home. I believe that elders’ wishes should always be honored if at all possible. If a person doesn’t want to take non-essential pills (like vitamins), or if a person wants to bathe just once a week, that’s fine. But it’s not OK for an elder to be living in a home filled with piles and piles of paper. That’s a fire hazard. Clearing paths through the mess is not enough. It’s not OK for an elder to be living surrounded by rat feces. That’s a health hazard.

Of course, all elders who are able should be able to make their own decisions. Just make sure that self-neglect really is a decision, and not the sign of a deeper problem.

One of the most common complaints I encounter doing elder care house calls is this: “My—father/mother/aunt/uncle/grandmother—will not cooperate with care. We’re just trying to help, and our loved one fights us every step of the way!” There are so many reasons that the elderly may resist treatment: anxiety, delusions, frustration, old resentments, a desire for control. I could easily write a book on this topic alone.

But one of my key findings is that, for us as family members and elder care practitioners, it’s easy for us to overlook two simple causes for an elder's resistance to treatment: low-level pain and a lack of pleasure in life.

Often, I try two simple solutions before looking for deeper causes:

• I prescribe 500 mg of Tylenol, three times a day. It’s amazing how much more cooperative people become when they’re not constantly burdened by arthritis, headaches, or other ignored pains they may be suffering.

• I prescribe ice cream. One of the difficult realities of growing older and of suffering from dementia is that it’s easy to go days and days without feeling pleasure or joy in life. Elders may lack the mobility or cognitive ability to participate in activities they once enjoyed, whether that’s bridge, golf, reading or needlework. But everyone, even the most frail and ill among us, can enjoy a dish of ice cream. There are even delicious ice creams for diabetics.

Of course, if these simple measures don’t work, more investigation is in order. But as a geriatric specialist, I’ve found that the power of simple over-the-counter painkillers and ice cream is undeniable. Let's allow our care practices to reflect our compassion.